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R APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address T RP BL MdQat 33 � City Lot Size10c Oe N- — PM Owner's Name Address I ~� N� M" r C W d Phone) is^�,e� Contractor vet-( tLr q e__w s_jc Address r) LT.OAYP-TU_T-ST License No. ___—__Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �k Al-4 A.-,cVOCZ(NS I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._�_ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL�QCZ— PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS q Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation p� - Dia. of Well Casing ❑ Domestic/Private Gravel Pack Tracy Type of Casing 1t/ Specifications ❑ Public 17 Other ❑ Delta Depth of Grout Seal _ Type of Grout Ekrul&'_}C1V' 11 Irrigation L_p_Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work opne Well Destruction 171 Well Diameter �" Sealing Material (top 155q'� ppC- �..-,, — Depth L� Filler Material (Belowfid) —. 420 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 17 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms_ Character of soil to a depth of 3 feet. _ _ ___ ____ _Water table depth_ SEPTIC TANK I ) Type/Mfg _._ ___ Capacity__--.__ No. Compartments _ PKG. TREATMENT PLT. I I Method of Disposal Distance to nearest: Well _- Foundation _ Property Line LEACHING LINE I 1 No. & Length of lines _ _ Total length/size FILTER BED I I Distance to nearest: Well Foundation ___ Property Line SEEPAGE PITS I I Depth ___ Size Number------ _— SUMPS 1-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmar2 s compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certy that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call for I requi d inspe ions. Complete drawing on reverse//side. Signed ' Title- Date: -- D TMENT USE ONLY 17 Application Accepted b LL_ Date "� Area Pit or Grout Inspection by u Date o Final Inspection by Additional Comments: '� —/--;< ❑ Stk 466-6781 1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trac 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH r EH 13-241REV.I'M51 EH 14-2e 1 1